Pediatric emergency medicine trisk 2127 2127
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to penicillin, a 10-day course of a narrow-spectrum (first-generation) oral
cephalosporin is indicated. However, as many as 5% to 10% of penicillin-allergic
people also are allergic to cephalosporins. Patients with immediate or type I
hypersensitivity to penicillin should not be treated with a cephalosporin; in these
patients, oral clindamycin (20 mg/kg/day in three divided doses; maximum, 1.8
g/day) for 10 days is an acceptable alternative. Additionally, an oral macrolide or
azalide (such as erythromycin, clarithromycin, or azithromycin) is also acceptable
for patients allergic to penicillin. Therapy for 10 days is indicated except for
azithromycin (12 mg/kg/day; maximum, 500 mg on day 1, then 6 mg/kg/day;
maximum, 250 mg/day), which is given on days 2 through 5.
CANDIDAL VAGINITIS
Clinical Considerations
Clinical Recognition
Candidal vaginitis is one of the most common causes of vaginitis in pubertal
adolescents. C. albicans frequently colonizes the vagina after the onset of puberty
when estrogen stimulates local increases in glycogen stores and acidity that both
appear to enhance its growth. If the ecologic balance of the vagina is changed by
inhibition of the normal bacterial flora, impaired host immunity, or an increase in
the availability of nutrients (broad-spectrum antibiotics, immunodeficiency states,
corticosteroids, diabetes mellitus, pregnancy), the resulting proliferation of
Candida may produce symptoms. However, most patients with candidiasis have
no identifiable predisposing risk factors. Because of the importance of estrogen in
promoting fungal growth, candidal vulvovaginitis is rare among prepubertal girls.
Clinical Assessment
The most common clinical manifestation of vulvovaginal candidiasis is vulvar
pruritus. In severe infections, vulvar edema and erythema can occur. “External”
dysuria is produced when urine comes in contact with the inflamed vulva. Vaginal
discharge is variable in quantity and appearance. In severe cases, the vaginal vault
is red, dry, and has a whitish, watery, or curd-like discharge that may be relatively
scanty. Patients with mild disease may have only intermittent itching and an
unimpressive discharge.
The diagnosis can be made with the presence of C. albicans on wet mount,
Gram stain, or culture of vaginal discharge in a patient with vaginitis symptoms;
however, candidiasis is most often a clinical diagnosis—testing can be limited to
patients who are not responding to appropriate therapy or if an alternative
